Chapter 16

Pregnancy at Risk: Conditions

that Complicate Pregnancy

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 Pregnancy at Risk: Conditions that
Complicate Pregnancy

• More women are entering pregnancy with chronic medical

conditions
• You will assist the registered nurse (RN) to provide care
for the pregnant woman at risk
• Maternal–fetal medicine

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 Pregnancy Complicated by Medical
Conditions
• Risk factors for the pregnant woman
– Chronic medical conditions
– Acute infections
• Several ways in which pregnancy, medical conditions
interrelate
– Normal physiologic changes of pregnancy can
alleviate or intensify illness symptoms
– Medical conditions can affect progress, outcome of
pregnancy

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 Diabetes Mellitus

• Chronic disease: Glucose metabolism is impaired by lack

of insulin in the body or ineffective insulin utilization
– Poorly controlled, can adversely affect pregnancy
outcomes
– Challenging to manage in pregnancy
• Complicates approximately 3% to 10% of pregnancies
• Specialists should be involved in the care of the pregnant
woman with DM

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 Diabetes Mellitus (cont.)
• Classification of diabetes mellitus
– Pregestational diabetes mellitus (DM)
• Type 1 DM
• Higher incidence of spontaneous abortion
(miscarriage)
• Diabetic woman is more likely to experience a
cesarean birth

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 Diabetes Mellitus (cont.)
– Pregestational diabetes mellitus (DM) (cont.)
• Fetus at high risk for birth defects, stillbirth
• Poor glycemic control = several likely
complications
‒ Hypertensive disorders
‒ Polyhydramnios (excess levels of amniotic fluid)
‒ Preterm delivery
‒ Shoulder dystocia in the infant

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 Diabetes Mellitus (cont.)
• Gestational DM
– Increased risk for developing type 2 DM after
pregnancy: 30% to 50% within five to 20 years
postdelivery
– Underlying pathophysiology of GDM: Insulin resistance
– Diabetogenic effect of pregnancy
– Greatest risk for the fetus is macrosomia
– Screen for GDM at approximately 24 to 28 weeks’
gestation; as early as 20 weeks

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 Diabetes Mellitus (cont.)

• Treatment
– Prepregnancy care
– Monitoring glycemic control
– Maintaining glycemic control
• Insulin therapy
• Oral hypoglycemic agents
• Diet therapy
• Exercise

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 Diabetes Mellitus (cont.)

• Treatment (cont.)
– Fetal surveillance
– Determining timing of delivery

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 Diabetes Mellitus (cont.)
• Nursing process for the pregnant woman with DM
– Assessment
– Selected nursing diagnoses
– Outcome identification and planning
– Implementation
• Monitoring management of therapeutic regimen
• Preventing maternal injury
• Monitoring for, preventing infection
• Monitoring fetal status; estimating fetal weight
– Evaluation: Goals and expected outcomes
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 Question
Gestational diabetes is a form of diabetes mellitus that
occurs during pregnancy. It is caused by insulin resistance.
What is the result of gestational DM in a normal
pregnancy?
a. Blood glucose levels are higher than normal (mild
hyperglycemia) after meals
b. Blood glucose levels are higher than normal (mild
hyperglycemia) when fasting
c. Blood glucose levels are lower than normal (mild
hypoglycemia) after meals
d. Insulin levels are decreased (hypoinsulinemia) after
meals
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 Answer
a. Blood glucose levels are higher than normal (mild
hyperglycemia) after meals

Rationale: The result in a normal pregnancy is threefold:

1. Blood glucose levels are lower than normal (mild
hypoglycemia) when fasting
2. Blood glucose levels are higher than normal (mild
hyperglycemia) after meals
3. Insulin levels are increased (hyperinsulinemia)
after meals
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 Cardiovascular Disease
• Clinical manifestations and diagnosis
– Signs, symptoms vary related to underlying cause of
heart disease
– Earliest warning sign of cardiac decompensation is
persistent rales in bilateral lung bases
• Treatment: Team approach
– Activity levels
– Stress management
– Diet and medications
– Management during labor and the postpartum period

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 Cardiovascular Disease (cont.)

• Nursing care
– Excellent nursing assessment and reporting of
abnormal findings is critical
– Primary nursing import: Monitor for, teach woman to
recognize signs of cardiac decompensation
– Emphasize infection prevention
– Teach clot formation avoidance strategies

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 Cardiovascular Disease (cont.)
• Nursing care (cont.)
– Recommend adequate rest, to avoid strenuous
physical activity
– Inquire about illicit drug use and cigarette smoking
– Assist the woman with tests for fetal well-being
– Monitor the woman particularly closely during labor
– Discourage active maternal pushing during second
stage of labor
– Postpartum period: Immediately report fever,
increased bleeding, any signs of decompensation

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 Anemia
• Iron-deficiency anemia
– Clinical manifestations and diagnosis
• Common signs and symptoms: Tachycardia, tachypnea,
dyspnea, pale skin, low blood pressure, heart murmur,
headache, fatigue, weakness, and dizziness
• Pica (ingestion of nonfood substances such as clay
and laundry starch); pagophagia (frequent chewing
or sucking on ice)
• Hemoglobin levels <10 g/dL define anemia during
pregnancy
– Treatment

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 Anemia (cont.)
• Sickle cell anemia
– Clinical manifestations and diagnosis
• Woman rarely experiences symptoms
• Crises triggered by stress: Infection, hypoxia,
trauma, cold, dehydration
• At risk for a sickle cell crisis at any time during the
pregnancy
• May experience recurrent bouts of pain in the
joints, bones, chest, and abdomen
– Treatment
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 Anemia (cont.)
• Nursing care
– Iron-deficiency anemia
• Nutritional counseling
‒ Vitamin C enhances iron absorption; folate
‒ Iron supplements predispose to constipation
– Sickle cell anemia
• Support and teaching; prevent crises
• Important: Adequate fluid intake, rest

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 Question
A pregnant woman with cardiovascular disease can usually
continue to take her cardiac medications during pregnancy.
What medication cannot be continued during pregnancy?

a. Digoxin
b. Heparin
c. Hydrochlorothiazide
d. Coumadin

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 Answer
d. Coumadin

Rationale: The woman usually can continue to take her

cardiac medications during pregnancy, with the exception
of warfarin (Coumadin), angiotensin-converting enzyme
(ACE) inhibitors, and angiotensin II receptor blockers.
Warfarin crosses the placenta and increases the risk of
congenital anomalies.

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 Asthma

• Clinical manifestations and diagnosis

• Treatment
– Management of acute exacerbation
– Labor and birth management
• Nursing care
– Teaching is a major role
– Smoking cessation and control of the environment

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 Epilepsy
• Clinical manifestations
• Treatment
– Current recommendations: Remain on med(s) which
most effectively control seizures
• Status epilepticus
• Nursing care
– Teaching: Careful compliance with treat regimen
– Teaching: Importance of consuming food high in folic
acid, high-dose folic acid supplementation
– Provide emotional support during prenatal testing for
fetal anomalies

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 Infectious Diseases
• TORCH
– Toxoplasmosis
– Other infections (teratogenic)
• Hepatitis B
• Syphilis
• Varicella
• Herpes zoster
– Rubella
– Cytomegalorivus (CMV)
– Herpes simplex virus (HSV)
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 Infectious Diseases (cont.)

• Prevention is the focus of interventions because many of

the TORCH infections do not have effective treatment
regimens
• Routine screenings for hepatitis B, syphilis, and rubella
• TORCH screen
• Latent (“old”) infection

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 Infectious Diseases (cont.)

• Sexually transmitted infections

– Many are reportable diseases tracked by the CDC
– Chlamydia: Most common bacterial STI in US
• Untreated chlamydia increases HIV/AIDS risk
• Pelvic inflammatory disease (PID)
– Gonorrhea: Second most reported
• Resistance to antibiotics
• Can lead to PID
• Infertility can result

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 Infectious Diseases (cont.)

• Sexually transmitted infections (cont.)

– Human papillomavirus (HPV)
• Most common viral STI in US
• Genital warts tend to increase in size during
pregnancy: Heavy bleeding during vaginal delivery
• Neonatal HPV infection can result in life-
threatening laryngeal papillomas

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 Infectious Diseases (cont.)

• Sexually transmitted infections (cont.)

– Trichomoniasis (protozoan infection)
• Associated with adverse pregnancy outcomes
– HIV/AIDS
• Importance in knowing maternal HIV status
−Prevent transmission to baby
• Clinical manifestations

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 Infectious Diseases (cont.)

• Sexually transmitted infections (cont.)

– HIV/AIDS (cont.)
• Treatment: Two main maternal goals
−Prevent maternal progression of the disease
−Prevent perinatal transmission of virus to the
fetus

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 Infectious Diseases (cont.)
• Sexually transmitted infections (cont.)
– HIV/AIDS (cont.)
• Nursing care
‒ Assure confidentiality
‒ If woman is HIV-positive, ensure her understanding
of risk to her sexual partners
‒ Explain risks of perinatal transmission of HIV and
benefits of therapy
‒ Explore her understanding of the treatment regimen

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 Infectious Diseases (cont.)

• Nursing process for the pregnant woman with an STI

– Assessment
– Selected nursing diagnoses
– Outcome identification and planning

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 Infectious Diseases (cont.)
• Nursing process for the pregnant woman with an STI
(cont.)
– Implementation
• Controlling risks for STIs
• Maintaining immune status and protection from
additional infections
• Ensuring knowledge of STIs and treatment regimen
• Enhancing self-esteem
• Reducing anxiety
– Evaluation: Goals and expected outcomes

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 Question
TORCH is an acronym for a special group of infections that
can be acquired during pregnancy and transmitted
through the placenta to the fetus. Why is TORCH so
important during pregnancy?

a. Macrocephaly can occur

b. Can cause postmature delivery
c. They are teratogenic
d. Can cause hepatospleno-growth retardation

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 Answer

c. They are teratogenic

Rationale: Each infection is teratogenic with different

effects, depending upon when the infection occurs during
pregnancy.

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 Pregnancy Complicated by Intimate
Partner Violence
• Clinical manifestations and diagnosis
– Cycle of violence
• Three identifiable phases
– Warning signs
• Treatment
– Routine screening of all women is key to assisting
those who are ready to report abuse and receive help
– Interventions for the victim of IPV are directed
toward safety assessment and planning

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 Pregnancy Complicated by Intimate
Partner Violence (cont.)
• Nursing care
– Assist the RN to assess for abuse
– Determining whether to leave an abusive relationship
must be made exclusively by the woman
– Always document the woman’s responses to
questions about IPV
– Respond with supportive statements
– Document assessment objectively
– Be knowledgeable about local resources

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 Pregnancy Complicated by Age-Related
Concerns
• Adolescent pregnancy
– Clinical manifestations
• Many pregnant teens seek late prenatal care
• May be fearful of disclosing her pregnancy
– Treatment
• Best treatment for teenage pregnancy: Prevention
• Advocacy for pregnant adolescent
• Help teen to develop an adequate support network

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 Pregnancy Complicated by Age-Related
Concerns (cont.)
• Adolescent pregnancy (cont.)
– Nursing care
• Caring for developmental needs
‒ Pregnancy does not change developmental tasks,
it may complicate the issues
• Caring for physical needs
‒ Adequate nutrition is essential
• Caring for emotional and psychological needs
‒ Be knowledgeable about community resources for
the pregnant teen
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 Pregnancy Complicated by Age-Related
Concerns (cont.)
• Pregnancy in later life
– Clinical manifestations
– Treatment
– Nursing care
• Approach the older pregnant woman with an open
mind
• Tailor teaching to maternal needs
• Encourage questions at visits

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 Question

Tell whether the following statement is true or false.

Intimate partner violence (IPV) is a reality in our society. It

is important to assess every pregnant woman for IPV
because pregnancy is a very vulnerable time for a woman
in a relationship where IPV is a component.

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 Answer
True

Rationale: Pregnancy is a vulnerable time for a woman. IPV

may begin or escalate during pregnancy, particularly if
the pregnancy is unplanned. Researchers estimate that
4% to 8% of all pregnant women experience abuse
during pregnancy.

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